NURSING CARE ANALYSIS RECORD

(Maternal and Child Care Nursing)

Name :________________________________________

Level/ Section :________________________________________

RLE Instructor :________________________________________

Date Submitted :________________________________________

Grade:________________
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I. Content:__________________________________ 90% ________________

Assessment___________________________ 30%

Anatomy and physiology/ _________________ 10%

Pathophysiology

Laboratory and Diagnostic Examination _______ 10%

Drug Study ______________________________10%

Nursing care Plan__________________________30%

II. Presentation:____________________________ 5% _________

Neatness , Organization & Format __________5%

III. Punctuality: ____________________________ 5%_____________

REMARKS: ________________________________________________________________

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Name and signature of clinical instructor: _______________________________________

 CASE ABSTRACT
This is a case of a client named patient JPD, lived in Tagmalinao Cagwait Surigao Del Sur.
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Born on February 8, 1985, a highschool graduate. The name of the baby’s father is Jocel
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And it is stated in her history of present illness that she went to the hospital for evaluation.
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She was diagnoses to have GDM at 29 weeks and was initially advised to control her diet
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And did not prescribed on any medication.

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LEARNING OBJECTIVES:
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To quantify the weight gained of the mother during pregnancy.

To summarize the nutritional needs of the mother and the infant.

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To discuss the need to detect GDM in pregnancy

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Identify tools to modify risk factors in the postpartum period in order to reduce incidence of
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diabetes.
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ADMISSION DATA:

JPD 01-12-2021
Name: _______________________________Date & Time of Admission:__________________

Arrived Via: ✓ Wheelchair Stretcher Ambulatory

76 kg 147 cm
Weight:___________Height:___________ 110/90 bpm
Blood Pressure: R ___________L _____________

37
Temperature __________Pulse 80
__________ 20
Respiration _____________________________

Source providing Information: ✓ Patient Others ______________________

Early monitoring
Reason for consultation:_______________________________________________________

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Diagnosis:__________________________________________________________________

BIOGRAPHICAL DATA:

36
Age:__________ F
Sex:__________ Married
Marital Status: _____________Religion: Iglesia ni Cristo
_____________

Tagmalinao Cagwait Surigao Del Sur

Address:___________________________________________________________________

________________________________________________ Tel# ______________________

02/08/1985
Date of Birth:______ Tagmalinao Cagwait Surigao Del Sur
_______________Place of Birth:________________________________

Highscool graduate Unemployed _______

Educational Attainment:_________________________Occupation:______________
Filipino, Bisaya
Dialect/language Spoken:_________________________ _____________________________
Jocel
Name of the father of the baby:_____________ 38
_____________His Age: _________________

Emergency Contact:______________________________Phone number:_________________

NURSING HISTORY

Confinement prior to labor due to early monitoring of GDM

Chief complaints: ___________________________________________________________

History of present illness ( onset of labor):

A 36 yr old G3P2 patient currently at 30 weeks of gestation went to the hospital for evaluation
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The patient was diagnosed to have GDM at 29 weeks, initially advised to control her diet and
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was not prescribed on any medications.

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Past medical history :

Chicken
Childhood illnesses: pox
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Completestatus:
Childhood immunization immunization
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none
Allergies:_____________________________________________________________________

none __________________________________________________________
Accident and injuries:

none
Hospitalization:________________________________________________________________

Family History:

Health state and ages of: (cause of death if deceased)

Diabetes (mother)
Parents: ____________________________________________________________________

Pneumonia (eldest sister)

Siblings:____________________________________________________________________

none
Spouse: ____________________________________________________________________

none
Children: ____________________________________________________________________

Diabetes (mother)
Illness in the family similar to the client: ____________________________________________

Genogram
Obstetric History:
Feb 26, 2020
What was the first day of your last normal period (LMP)?_____ ______________________

___

December 27 2020
Expected date of delivery: ____________________________Age 30 weeks
of Gestation: ____________

✓
Do you normally have a period every month? _________ Yes _______No_________ Every days

✓
Have you had any bleeding since your last period?________ Yes _______ No

What day was your pregnancy test first positive?_____May 2020

_______________________________

✓
Were you on birth control when you got pregnant? ____________________ Yes _______ No

Please list all medications that you are currently taking: ______________________________

MENSTRUAL HISTORY(complete even if post-menopausal or no longer having periods)

13
Age at first period: _______years.

28
If your menstrual periods are regular; periods start every:_________________________days

lf your menstrual periods are irregular; periods start every:______to ______days (e.g.,12 to 60)

5-6
 Duration of bleeding: ____________________________days

✓
Does bleeding or spotting occur between periods? ______ Yes _______ No

✓ No
Does bleeding or spotting occur after intercourse?______ Yes_______

✓
Is pain associated with periods? ______ Yes _______No_______Occasionally

✓
If yes is it : before menses? _______during_______menses? _______both?

PAST OBSTETRICAL HISTORY (GTPAL )(List all pregnancies including miscarriages, abortions,tubal/ectopic)

Date Number of Length of pregnancy Living D&C Vaginal/ Place of Complications

Delivery
C-Section
Pregnancy

(Gravida)

Full Premature Abortion

Term

✓
2010 G1P0 C-section Surigao
✓
hospital

✓
2013 G2P1 C-section Surigao
hospital

2020 G3P3
GYNECOLOGIC HISTORY

Have you ever had an abnormal pap smear? _____________No __________ Yes When? ____________

What treatment was done? _____________________________________________________________

If yes, what type(s) of treatment have you had? _____ laser _____ cone biopsy _____ loop
excision (LEEP)

When was your most recent pap smear? ______________________Results? _____________________

Have you ever had:

_____ Gonorrhea _______ HIV/AIDS

_____ Chlamydia ______ Hepatitis A/B/C

_____ Herpes ______ Syphilis

_____ HPV/Genital warts ______ Endometriosis

_____Pelvic inflammatory disease ______ None Venereal

Vaginal infections Other ______________________________________

Have you or anyone in your family ever had any major problems with anesthesia? __Yes __No

Explain: _____________________________________________________________________________

Would you accept a blood transfusion if needed in case of emergency?______ Yes ______ No

Was anyone in your family or the father of the baby’s family born with any birth defects?

Thalassemia: _____Yes _______ No

Spina Bifida/Anencephaly: _____ Yes ______ No

Congenital Heart Defect: _____ Yes ______ No

Down Syndrome: ______ Yes _____ No

Tay-Sachs: ______ Yes _____ No

Sickle Cell Disease/Trait: _____ Yes _____ No

Hemophilia: _____ Yes _____ No

Muscular Dystrophy: _____ Yes _____ No

Cystic Fibrosis: _____ Yes ______ No

Huntington’s Chorea: _____ Yes _____ No

Birth control pills

What birth control method(s) do you currently use? _______________________________

PAST OBSTETRICAL/GYNECOLOGICAL SURGERIES

Check any that apply: or None

SURGERY YEAR SURGERY YEAR

NONE
D&C ovarian surgery

NONE
hysteroscopy L cyst(s) removed ovarian

NONE surgery
infertility R cyst(s) removed ovarian

NONE
tuboplasty L ovary removed

2021
NONE
tubal ligation R ovary removed

NONE
laparoscopy vaginal or bladder repair

NONE
hysterectomy (vaginal) for prolapse or incontinence

NONE
2010
hysterectomy cesarean section
(abdominal)

NONE
myomectomy other(specify)____________________
MAMMOGRAM HISTORY

NONE_______
Date of last mammogram: _______

✓ No _____Yes
Have you had an abnormal mammogram? _____

CURRENT HEALTH STATUS:

A. Activity and Rest Pattern:

Frequency & Duration of Exercise: The patient performs adequate exercise.

Limitations in Activity: Patient is limited to move during activities.

Complaint of Fatigue: The patient is constantly tired.

Usual Number of Hours of Sleep at Night: 10 hrs at daytime: 4 hrs

Number of Hours of sleep needed to feel rested: 8-10 hrs of sleep the patient feels rested.

Any change in sleep pattern? No changes in sleeping pattern.

Any routine preparation before going to sleep? Meditate before sleeping

B. Oxygenation and Circulation pattern:

Presence of Cough: No presence of cough. Duration:______________________

Presence of Chest Pain:No presence of chest pain. (Location, Frequency, Duration and Type of
pain)

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History of Heart disease?: No history of Heart disease HPN? No history of hypertension.

History of Asthma, PTB in the family? No history of Asthma and PTB in the family.

Do you smoke?: The patient does not smoke. Number of cigarettes per day?:_____________

Shortness of breath?: The patient is experiencing shortness of breath.

Coldness of extremities?: No coldness of extremities occurs.

Usual or Known BP: 110/90

C. Nutritional-Metabolic patterns:

Food preference: The patient prefers salty food. Food restrictions: Salty and sweet food.

Any change in diet?: limited carbohydrate intake.

Any change in appetite?: The patient doesn’t have a change in appetite.

Medication used related to diet: No medications intake related to diet.

Volume & Type of fluid taken per day: Water at least 5-8 glasses per day.

Source of water supply for drinking: The patient drinks mineral water.

Nausea and vomiting: The patient is experiencing dizziness and extreme nausea and vomiting.

Management: The patient drinks a lot of water.

D. Elimination Pattern:

a. Bladder

Frequency & amount of urination per day: at least 4-5 times per hour.

Color & Odor of Urine: The urine bright color yellow and has a strong, pungent odor.

Any discomfort in urination: No discomfort during urination.

Intervention done:__________________________________________________

Changes: _________________________________________________________

Intervention done: __________________________________________________

b. Bowel:
 Frequency of bowel elimination per day: 2 times a day

Consistency & color of stool: Type 3 stool, solid and brown color.

Any discomfort in bowel elimination: No discomfort in bowel elimination.

Intervention done:_____________________________________________________

c. Senses:

Any difficulty in:

Seeing: No difficulties in sense of sight.

Hearing: No difficulties in sense of hearing.

Feeling (touch): No difficulties in sense of touch.

Tasting:No difficulties in sense of taste.

Smelling:No difficulties in sense of smell.

How long have you had the difficulty?__________________________________________

How did you manage it?_____________________________________________________

How did this affect your lifestyle?______________________________________________

MEDICAL HISTORY:

✓ No major problem

Cardiac________________________ Gastro_____________________________
 Hyper/Hypotension_______________ Arthritis_____________________________

Diabetes_______________________ Stroke______________________________

Cancer________________________ Seizure_____________________________

Respiratory_____________________ Glaucoma___________________________

Allergies & reactions:________________ others______________________________

Drug: _______________________

Food: _______________________

Signs & Symptoms:___________________________________________________

Surgery Date

____________________________ ___________________________

_____________________________ ___________________________

PSYCHOSOCIAL HISTORY:

Recent Stress: emotional distress is present.

Coping Mechanism: Doing household chores

Support System: The patient receives support from husband and family.

Tobacco Use:_____________Alcohol Use:_________________

Drug use:___________________________________________

PHYSICAL EXAMINATION

Date Performed______________________ Hospital day # (Patient) __________________

I. GENERAL SURVEY: (Appearance & Mental Status)

 Body build, height & weight proportional to age ……. ✓ Yes No
v
Relaxed, erect posture, coordinated movement…….

In standing, sitting & walking……………….. ✓ Yes No

✓
Clean, Neat…………………………………………….. Yes No

Body Odor………………………………………………. Yes ✓ No

✓
Distress noted…………………………………………... Yes No

Obvious signs of illness…………………………………. Yes ✓ No

✓
Cooperative………………………………………………. Yes No

Responses appropriate to the situation……………….. ✓ Yes No

Understandable speech………………………………… ✓ Yes No

Relevant and Organized thoughts…………………….. ✓ Yes No

II. VITAL SIGNS, HEIGHT & WEIGHT:

37
Temperature:_________ 80
______ Pulse:________________Respiration: 20
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110/90 147 cm 76 kg
Blood Pressure: L___________ R____________Height:_____ ____Weight:____ _____

III. INTEGUMENT :

Skin: Light brown Deep brown

✓
Pallor Cyanosis jaundice

✓
No edema Edema present:_______________

Lesion present:__________________ Abrasion present: _____________

 Excessive moisture Excessive dryness

IV. HEAD:

✓
Hair: Evenly distributed Patches of loss hair

✓ ✓
Thick Thin Silky, resilient Brittle, dry

✓
No infestation Lice, nits

✓
Skull: Rounded, symmetrical, smooth Lack of symmetry

✓ Absence of nodules or masses & depression

Local deformities from trauma

Face: ✓ Symmetrical facial features

Exophthalmos

Periorbital Moon face

Chloasma Sunken eyes

Eyes & Vision:

Bulbar: sclera appears white and capillaries are evident.
Color of conjunctiva________________________________________________
Transparent and shiny
Clarity of cornea___________________________________________________
Black pupils, equal size, round.
Color, shape & symmetry of size of pupils_______________________________
Pupils constrict when looking at a near object and dilate when
Pupil’s reaction to accommodation_____________________________________
looking at far object.
Both eyes are coordinated.
Ocular movement__________________________________________________

The patient can see object in peripheral vision.

Visual Activity_____________________________________________________
Ears:
Color as same as facial skin, symmetrical in shape.
Color & shape of auricle: ______________________________________________

Aligned with outer canthus of the eye.

Position: ___________________________________________________________

No discharges.
Discharges/growth: ___________________________________________________
Normal voice tones, audible.
Response to normal voice tones: _________________________________________

Nose:
Symmetrical in shape and straight, uniform in color.
Shape & color: _______________________________________________________

No discharges.
Discharges/growth: ____________________________________________________

Mouth & Pharynx:

32 ✓
Teeth: ____________complete__________dentures __________ carries__________

Both color pink.

Color of lips & buccal mucosa: ____________________________________________
Pink in color, central position, looks smooth.
Color, position & texture of tongue: _________________________________________

Moves freely, no tenderness.

Tongue movement: _____________________________________________________

Pink
Color of gums: _________________________________________________________

V. NECK
Proportional to the size of the head, symmetrical
Muscle size/ symmetry: __________________________________________________
Smooth movement with no presence of discomfort.
Head movement: _______________________________________________________

Lymph nodes: ____________________________Thyroid glands:__________________

Assends during swallowing but not
visible on inspection
No presence of melasma
Melasma: ______________________________________________________________

VI. UPPER EXTREMITIES

Presence of acne, nail is convex curvature and smooth.
Skin & Nail: __________________________________________________________
 Muscle strength & tone: _________________________________________________

Full range of motion.

Joint range of motion: ___________________________________________________
70 bpm
Brachial pulses:_____ 80
_______________Radial pulses: ________________________

No presence of palmar erthyma.

Palmar erythema: ______________________________________________________

VII. CHEST & BACK:

Symmetry: ___________________________Size & shape:_______________________

Spine alignment: _________________________________________________________

Breathing pattern: _____________________ Breath sounds: _____________________

Respiratory muscle movement: _____________________________________________

Heart sounds:__________________Pitch:_______________Intensity:_______________

Extra sounds/beats:_____________________Murmurs: __________________________

Breast symmetry:_______________________Contour: ___________________________

No tenderness Enlargement of size
Discharge:___________________Lymph nodes:__ ________Growth:________________

VIII. ABDOMEN:

Symmetry:_____________________Size:____________Shape:__________________

Abdominal sounds:______________________Growth: __________________________

Presence of striae gravidarum
Visible linea nigra
Striae Gravidarum: ______________________Linea Nigra: _______________________
30 cm
Fundic height: ______________Fetal heart tone: 135 bpm
__________/ Left occiput posterior
min. Location:_________

IX. GENITALS
No presence of swelling Presence of white milky discharge
Growth: _______________________Discharge: ________________________________
 X. ANUS & RECTUM:
No presence of swelling
Growth: _______________________Discharge: None
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XI. LOWER EXTREMITIES:

Skin & toenails:__________________________________________________________

Gait & balance:__________________________________________________________

Joint range of motion: _____________________________________________________

Femoral pulses:_________________________Popliteal pulses:____________________

Posterior tibial pulses:____________________Pedal pulses:_______________________

Bi-pedal Edema: ________________________Grade: ____________________________

Tendon & Plantar reflexes:_________________Spider angiomata : __________________

PRENATAL CHECK UP

Trimester
1st 2nd 3rd

AOG IN MONTHS 2 or 3 4 5 6 7 8 9

DATE OF THIS VISITS

VAGINAL BLEEDING (Y/N)

URINARY TRACT INFECTION (Y/N)

 1WEIGHT IN KG.

BLOOD PRESSURE

BP 140/90 AND ABOVE (Y/N)

FEVER 39°C AND ABOVE (Y/N)

PALLOR (Y/N)

ABNORMAL FUNDAL HEIGHT (Y/N)

20 21-24 cm 25-26 28-30 cm 30-34 cm

cm cm

ABNORMAL PRESENTATION (Y/N)

MISSING FETAL HEARTBEAT

(Y/N)

EDEMA (Y/N)

VAGINAL INFECTION (Y/N)

LAB TEST RESULTS

( HBG, URINE, VDRL, OGTT, HEPA-B)

ACTION
 IRON/FOLATE #RX

ADVICE ON 4 DANGER SIGNS (Y/N)

CENTRAL CHECK-UP? (Y/N)

EMERGENCY PLANS AND PLACE

OF DELIVERY (Y/N)

RISK? (Y/N)

DATE OF NEXT VISIT

 NEW BORN

Name: ______________________________Gender: ________Male _________Female

Date of delivery: ________________Time of delivery:________Type of Delivery:________

APGAR SCORING: 1 minute _____________ 5 minutes: ________10 minutes ________

Temperature:_____________Cardiac Rate: _____________Respiratory Rate:__________

AOG: __________________ Birth Weight: ______________Length: _________________

Head circumference: _______chest circumference : ______abdominal circumference _____

Vitamin K: ________________Eye prophylaxis: __________Hepatitis B vaccine: ________

AOG: ____________By Ultra sound: __________Neuromuscular/physical maturity________

Analysis/implication: __________________________________________________________

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 PATHOPHYSIOLOGY /PHYSIOLOGY OF PREGNANCY

OF

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According to book As experienced by the patient

 TREATMENT

STANDARD ACTUAL

(According to the book) (Done to patient)

 ON-Going APPRAISAL
(Daily Condition of Patient)

Note: Start on the next day after assessment.

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DISCHARGED PLAN

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HEALTH TEACHING

EVALUATION OF LEARNING OBJECTIVES